Readability of Online Patient Educational Materials Related to Breast Lesions Requiring Surgery.

Purpose To evaluate readability of websites that are commonly accessed for information on breast lesions requiring surgery. Materials and Methods An internet search using three malignant and eight nonmalignant breast lesions that traditionally require lumpectomy or excisional biopsy as search terms was conducted to identify websites commonly accessed for patient information on breast lesions requiring surgery. Nine websites with information on breast diagnoses were identified based on search engine results for each breast lesion queried. Available patient-directed information was downloaded for each lesion from each website on May 15, 2018. Grade-level readability of downloaded content for each lesion was then determined by using generalized estimating equations, with observations nested within readability metrics from each website. Readability of associated terms breast biopsy, breast cancer, and breast surgery was also evaluated with the same method. Results were compared with American Medical Association (AMA) recommended readability parameters (sixth-grade reading level). All interval estimates were calculated for 95% confidence. Results Average grade level readability score of health information on breast lesions requiring surgery was 11.7, which exceeded the AMA parameters. Information on Wikipedia was written at the highest reading level (grade level readability score, 14.2), while information on the National Institutes of Health website ( http://cancer.gov ) was written at the lowest reading level (grade level readability score, 9.7). Educational materials on malignant breast lesions (grade level readability score, 12.3) were written at a higher reading level than were those on nonmalignant breast lesions (grade level readability score,11.4). Information on the terms breast biopsy (grade level readability score, 10.9), breast cancer (grade level readability score, 10.6), and breast surgery (grade level readability score, 11.1) were all written above a sixth-grade reading level. Conclusion Readability of current online resources on breast biopsy lesions traditionally requiring surgery may be too complex for the general public to comprehend, leading to misinformation and confusion. © RSNA, 2019 See also the editorial by Haygood in this issue.

Incidence and outcomes of incidental breast lesions detected on cross-sectional imaging examinations.

The aim of this study was to determine the frequency and outcomes of incidental breast lesions detected on nonbreast specific cross-sectional imaging examinations. A retrospective review of the medical records was performed to identify all patients without a known history of breast cancer, who had an incidentally discovered breast lesion detected on a nonbreast imaging examination performed at our institution between September 2008 and August 2012 for this IRB-approved, HIPAA compliant study. Outcomes of the incidental lesions were determined by follow-up with dedicated breast imaging (mammography, breast ultrasound, and/or breast MRI) or results of biopsy, if performed. Imaging modality of detection, imaging features, patient age, patient location at the time of the nonbreast imaging examination, type of follow-up, and final outcome were recorded. Rates of malignancy were also calculated, and comparison was made across the different cross-sectional imaging modalities. Kruskal-Wallis and Fisher's exact tests were used to identify factors associated with an increased rate of malignancy. Logistic regression was used to model the risk of malignancy as a function of continuous predictors (such as patient age or lesion size); odds ratios and 95% confidence intervals were obtained. A total of 292 patients with incidental breast lesions were identified, 242 of whom had incidental lesions were noted on computed tomography (CT) studies, 25 on magnetic resonance imaging (MRI), and 25 on positron emission tomography (PET). Although most of the incidental breast lesions were detected on CT examinations, PET studies had the highest rate of detection of incidental breast lesions per number of studies performed (rate of incidental breast lesion detection on PET studies was 0.29%, compared to 0.10% for CT and 0.01% for MRI). Of the 121 of 292 (41%) patients who received dedicated breast imaging work-up at our institution, 40 of 121 (33%) underwent biopsy and 25 of 121 (21%) had malignancy. There was a significantly increased rate of malignancy in older patients (odds ratio: 1.05, 95% CI: 1.02-1.093; P = .006). Additionally, patients with PET-detected incidental breast lesions had a significantly higher rate of malignancy (55%), compared to patients with CT-detected (35%) and MRI-detected (8%) incidental breast lesions (P = .038). The rate of malignancy upon follow-up of incidental breast lesions detected on nonbreast imaging examinations in this retrospective study was 21%, supporting the importance of emphasizing further work-up of all incidentally detected breast lesions with dedicated breast imaging. Additionally, we found that PET examinations had the highest rate of detection of incidental breast lesions and the highest rate of malignancy, which suggests that PET examinations may be more specific for predicting the likelihood of malignancy of incidental breast lesions, compared to CT and MRI.

Variability in the Management Recommendations Given for High-risk Breast Lesions Detected on Image-guided Core Needle Biopsy at U.S. Academic Institutions.

The purpose of this study was to describe and compare the management recommendations provided in the setting of a high-risk lesion diagnosed on core needle biopsy of the breast at academic institutions across the United States. We contacted breast imagers at U.S. academic institutions via email and asked them to complete a voluntary online survey. The survey consisted of eight questions regarding the management recommendations given when core biopsy yields various high-risk lesions. We received survey responses from 41 of the 59 institutions contacted (69% response rate). Surgical excision was the most frequently reported recommendation given for all high-risk lesions; however, the proportion varied from 95% for atypical ductal hyperplasia and papilloma with associated atypia, 76% for flat epithelial atypia, 73% for radial scar/complex sclerosing lesion, 71% for lobular carcinoma in-situ, 61% for atypical lobular hyperplasia, to 39% for intraductal papilloma without atypia. Our study demonstrates inconsistency in the management recommendations given for high-risk lesions detected on core needle biopsy at academic institutions nationally. This outcome suggests that patients may benefit from the creation of consensus recommendations for the management of high-risk lesions detected on core needle biopsy.

Variability in Individual Radiologist BI-RADS 3 Usage at a Large Academic Center: What's the Cause and What Should We Do About It?

RATIONALE AND OBJECTIVES: Although the breast imaging reporting and data system (BI-RADS) lists specific criteria for designating a lesion as BI-RADS category 3 (probably benign), there are no target benchmarks for BI-RADS 3 usage rates. This study investigates the variability of BI-RADS 3 rates among a group of academic breast imagers, with the goal of defining more precise utilization. MATERIALS AND METHODS: We retrospectively reviewed all diagnostic mammograms performed between July 1, 2013 and August 8, 2017 at our academic institution. The percentage of diagnostic mammograms given a BI-RADS 3 assessment was compared between radiologists using the Chi-square test. We then evaluated for correlation between BI-RADS 3 rate and individual clinical metrics (eg, radiologist experience, cancer detection rate [CDR] and recall rate) using univariate linear regression. RESULTS: The study included 13 breast imagers and 24,051 diagnostic breast examinations. There was significant variability in BI-RADS 3 rates between radiologists, ranging from 8.0% to 19.3% (p < 0.001). Increased BI-RADS 3 rates negatively correlated with BI-RADS 1 or 2 rate (p < 0.001) and positively correlated with recall rate (p = 0.03). There was no association between BI-RADS 3 rate and the radiologist's level of experience, BI-RADS 4 or 5 rate, or CDR. CONCLUSION: We found significant variability in BI-RADS 3 usage, which seems to be used in place of BI-RADS 1 or 2 findings rather than to avoid biopsy recommendation. BI-RADS 3 rates also directly correlated with recall rate, suggesting a greater degree of uncertainty among specific radiologists. Importantly, increased usage of BI-RADS 3 did not correlate with provider experience or improved CDR.

Characteristics and Outcomes of BI-RADS 3 Lesions on Breast MRI.

BACKGROUND: There are few data regarding the use and outcomes of Breast Imaging Reporting and Data System (BI-RADS) 3 assessment on breast magnetic resonance imaging (MRI). The aim of this study was to describe the imaging findings prompting a BI-RADS 3 assessment and to report their outcomes, including the timing of follow-up examinations. PATIENTS AND METHODS: We performed a retrospective study evaluating 199 breast lesions in 186 patients who were assigned a BI-RADS 3 assessment on breast MRI over a 5-year period. Clinical and imaging features were recorded. For outcomes analysis, lesions were considered benign if they showed 2 years of MRI stability, if they were declared benign during follow-up, or if the patient underwent biopsy with benign pathology results. Clinical and imaging features of BI-RADS 3 lesions associated with malignancy were assessed by the Fisher exact test, with P < .05 considered significant. RESULTS: Of the 199 breast MRI lesions assigned a BI-RADS 3 assessment, 80 (40%) of 199 were non-mass enhancement, 61 (31%) were a single focus, and 58 (29%) were masses. A total of 131 lesions (66%) were eligible for outcome analysis after excluding those lost to follow-up; 4 (3%) were diagnosed as malignant within the 2-year follow-up. Masses assigned a BI-RADS 3 assessment were more likely to be malignant during follow-up than non-mass enhancement or single focus (P < .05). CONCLUSION: Despite limited data on the use of BI-RADS 3 at breast MRI, there is a low malignancy rate of 3% at our institution. Additional studies are needed to further define the appropriate use of BI-RADS 3 on breast MRI.

Robust Short-Lag Spatial Coherence Imaging of Breast Ultrasound Data: Initial Clinical Results.

Ultrasound is frequently used in conjunction with mammography in order to detect breast cancer as early as possible. However, due largely to the heterogeneity of breast tissue, ultrasound images are plagued with clutter that obstructs important diagnostic features. Short-lag spatial coherence (SLSC) imaging has proven to be effective at clutter reduction in noisy ultrasound images. M -Weighted SLSC and Robust-SLSC (R-SLSC) imaging were recently introduced to further improve image quality at higher lag values, while R-SLSC imaging has the added benefit of enabling the adjustment of tissue texture to produce a tissue signal-to-noise ratio (SNR) that is quantitatively similar to B-mode speckle SNR. This paper investigates the initial application of SLSC, M -Weighted SLSC, and R-SLSC imaging to nine targets in the female breast [two simple cysts, one complicated cyst, two fibroadenomas, one hematoma, one complex cystic and solid mass, one invasive ductal carcinoma (IDC), and one ductal carcinoma in situ (DCIS)]. As expected, R-SLSC beamforming improves cyst and hematoma contrast by up to 6.35 and 1.55 dB, respectively, when compared to the original B-mode image, and similar improvements are achieved with SLSC and M -Weighted SLSC imaging. However, an interesting finding from this initial investigation is that the solid masses (i.e., fibroadenoma, complex cystic and solid mass, IDC, and DCIS), which appear as hypoechoic in the B-mode image, have similarly high coherence to that of surrounding tissue in coherence-based images. This work holds promise for using SLSC, M -Weighted SLSC, and/or R-SLSC imaging to distinguish between fluid-filled and solid hypoechoic breast masses.

Factors Impacting False Positive Recall in Screening Mammography.

RATIONALE AND OBJECTIVES: Our objective was to identify factors impacting false positive recalls in screening mammography. MATERIALS AND METHODS: We retrospectively reviewed our screening mammography database from August 31, 2015 to September 30, 2016, including full field digital mammograms (FFDM) and digital breast tomosynthesis (DBT) mammograms. False positive (FP) exams were defined as Breast Imaging-Reporting and Data System (BI-RADS) 1 or 2 assessments at diagnostic imaging with 1 year cancer-free follow-up, Breast Imaging-Reporting and Data System 3 assessment at diagnostic imaging with 2 years cancer free follow-up, or biopsy with benign pathology. True positives were defined as malignant pathology on biopsy or surgical excision. We evaluated the association of FP recalls with multiple patient-level factors and imaging features. RESULTS: A total of 22,055 screening mammograms were performed, and 1887 patients were recalled (recall rate 8.6%). Recall rate was lower for DBT than full field digital mammograms (8.0% vs 10.6%, p < 0.001). FP results were lower if prior mammograms were available (90.8% vs 95.8%, p = 0.02), and if there was a previous benign breast biopsy (87.6% vs 92.9%, p = 0.01). Mean age for the FP group was lower than the true positive group (56.1 vs 62.9 years, p < 0.001). There were no significant differences in FP recalls based on history of high-risk lesions, family history of breast or ovarian cancer, hormone use, breast density, race, or body mass index. CONCLUSION: FP recalls were significantly less likely with DBT, in older women, in patients with prior mammograms available for comparison, and in patients with histories of benign breast biopsy. This study supports the importance of using DBT in the screening setting and obtaining prior mammograms for comparison.

An Abbreviated Protocol for High-risk Screening Breast Magnetic Resonance Imaging: Impact on Performance Metrics and BI-RADS Assessment.

RATIONALE AND OBJECTIVES: Annual breast magnetic resonance imaging (MRI) is recommended to screen high-risk populations for breast cancer, although costs are significant. This study assesses the performance of an abbreviated MRI protocol as a resource-efficient approach for screening patients at high-risk of breast cancer, and assesses whether the abbreviated protocol alters the assigned Breast Imaging Reporting and Data System (BI-RADS) category. MATERIALS AND METHODS: This is a prospective paired cohort study performed in an academic ambulatory setting. MRI images of women at high risk of breast cancer were reviewed using an abbreviated MRI protocol, followed by an immediate review of additional sequences included in a full diagnostic protocol. BI-RADS assessments, including all changes and interpretation times, were recorded for both the abbreviated and full protocol reviews. Cancer detection rate, positive predictive value 3 (PPV3), sensitivity, and specificity were calculated. RESULTS: A total of 1052 MRI cases were reviewed. The cancer detection rate was 13.3 per 1000 with a PPV3 of 30.4% based on the full protocol. Review of sequences included in the full protocol resulted in a change in the final BI-RADS assessments in 3.4% of the cases, the majority of which did not change clinical management with respect to biopsy. The sensitivity and specificity of the abbreviated and full protocols were not significantly different. CONCLUSIONS: This pilot study of an abbreviated MRI protocol demonstrates effective performance in cancer detection. BI-RADS assessments were rarely altered with the additional information afforded by the full protocol. The abbreviated protocol holds promise for resource-efficient breast cancer screening in high-risk women.

Strategies for Decreasing Screening Mammography Recall Rates While Maintaining Performance Metrics.

RATIONALE AND OBJECTIVE: This study aimed to determine the impact of interventions designed to reduce screening mammography recall rates on screening performance metrics. MATERIALS AND METHODS: We assessed baseline performance for full-field digital mammography (FFDM) and digital breast tomosynthesis mammography (DBT) for a 3-year period before intervention. The first intervention sought to increase awareness of recalls from screening mammography. Breast imagers discussed their perceptions regarding screening recalls and were required to review their own recalled cases, including outcomes of diagnostic evaluation and biopsy. The second intervention implemented consensus double reading of all recalls, requiring two radiologists to agree if recall was necessary. Recall rates, cancer detection rates, and positive predictive value 1 (PPV1) were compared before and after each intervention. RESULTS: The baseline recall rate, cancer detection rate, and PPV1 were 11.1%, 3.8/1000, and 3.4%, respectively, for FFDM, and 7.6%, 4.8/1000, and 6.0%, respectively, for DBT. Recall rates decreased significantly to 9.2% for FFDM and to 6.6% for DBT after the first intervention promoting awareness, as well as to 9.9% for FFDM after the second intervention implementing group consensus. PPV1 increased significantly to 5.7% for FFDM and to 9.0% for DBT after the second intervention. Cancer detection rate did not significantly change with the implementation of these interventions. An average of 2.3 minutes was spent consulting for each recall. CONCLUSION: Reduction in recall rates is desirable, provided performance metrics remain favorable. Our interventions improved performance and could be implemented in other breast imaging settings.